The Best Way to Improve Health Care Delivery Is with a Small, Dedicated Team

The Best Way to Improve Health Care Delivery Is with a Small, Dedicated Team

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Spurred by new payment models and new incentives, health systems are increasing their commitments to innovation in health care delivery. Unfortunately, many systems are overlooking an entire class of innovations that are modest in size, low in risk, and highly likely to deliver wins for both patients and profits.

These innovations take the form of small but full-time clinical teams that are commissioned to redesign and deliver care to a particular patient population. For example, in 1998, Essentia Health, in Duluth, Minnesota, put in place a small, full-time team to better serve patients discharged from the hospital with congestive heart failure (CHF), a team that initially consisted of just a nurse practitioner and a medical assistant supported by a part-time medical director and an on-call cardiologist.

A CHF diagnosis simply indicates that the heart is pumping an inadequate volume of blood, a weakness that can lead to accumulation of fluids and difficulty breathing. But “heart failure” sounds grave or even terminal, which commonly confuses patients. Left untreated, CHF can indeed kill you, but it can be kept in check for years when properly managed. The first few weeks after discharge is a crucial period.

Unfortunately, CHF patients, especially those who have been diagnosed with the condition for the first time, typically leave the hospital with a poor understanding of what they need to do to succeed. Even if the hospital staff has ample time to educate them, the patients are typically scared, sick, and medicated while in the hospital, so they may not retain much information. They may not comprehend the importance of their medications, make critical modifications to their diet, and respond as quickly as needed to changes in symptoms. After discharge, the patient’s primary care physician may not be available right away and may not have adequate time to thoroughly train the patient. As a result, avoidable emergency room visits and readmissions to the hospital are common.

The solution is not conceptually complicated: it amounts to time, trust, and education. Essentia’s full-time team, which by 2016 had grown to seven nurse practitioners and seven nurses, keeps close tabs on 2,500 CHF patients. The first interaction with the patient is the most important, taking place within one week of discharge. Over a lengthy appointment, the team focuses on building a relationship, understanding the patient’s full life, explaining the purpose of each medication, and, perhaps most critically, persuading the patient to call about any change in symptoms. The nurses on the team are immediately available for such calls. They also proactively check in with patients from time to time to deepen trust and help keep patients on track.

The result: Healthier patients, fewer hospitalizations, fewer emergency room visits. It is a clear win for both the patients and for the system.

Rare is the new drug or device that delivers such a double win. Those that do deservedly get the label blockbuster. Nonetheless, innovations like Essentia’s CHF program usually are not so revered.

In fact, innovations in the form of small, full-time teams that redesign care are rarely pursued at all because they are typically money losers under fee-for-service reimbursement.

It’s no surprise, then, that such opportunities have remained unexploited for decades. The “low-hanging fruit” metaphor may understate the case; these innovations are more like enormous watermelons just sitting on the ground.

Payment reform is the critical enabler. Also crucial, however, is that senior leaders in health systems recognize what these innovations look like.

A map of the innovation space can be helpful, and scholars in my field have developed any number of creative approaches. For our purposes, a one-dimensional map will suffice. Imagine a spectrum of innovation projects based on size — that is, the magnitude of the resources required to execute the project. On the left end of the spectrum you’d find any improvement that one person might execute in his or her spare time at work. On the right end is a capital-intensive project, perhaps one that involves building new facilities.

Three important notes about this simple map. First, the map does not suggest anything about the nature of the idea. You might find a new idea anywhere on the spectrum, or an old idea, a creative idea, a dull idea, an incremental idea, a radical idea, a sustaining idea, a disruptive idea, a high-tech idea, or a low-tech idea.

Second, there is no judgment built into this map about which innovations are important, exciting, or “cool.” There is important work to be done across the entire spectrum. On the left side of the spectrum you walk a mile by taking thousands of tiny steps, while on the right side you try to travel a mile in one giant leap. Neither approach is inherently better than the other.

Third, note that projects on the left end of the spectrum tend to be labeled improvement, while those on the right end are innovation. But there is plenty of overlap in the way these terms are used in practice, and there is little to be gained by trying to draw a sharp line between the two.

Now to the crucial point: There is enormous opportunity in the middle.

Sadly, few health systems are looking there. The pathology is as follows. Many health systems invest a lot of energy in quality improvement work, as well they should. These programs focus on innovation projects that can be executed in people’s spare time at work and within the currently defined context of their jobs. This is the left end of the spectrum.

When health systems choose to reach higher, the tendency is to jump all the way to the right end of the spectrum. The thinking seems to be that if we are going to do something truly innovative, not “just more improvement work,” then we have to think big. It has to be high-tech, disruptive, game-changing, or breakthrough. A notable symptom of this mindset is the spread of innovation “labs” or “centers” that operate essentially as think tanks. They brainstorm, do research, write proposals, and develop prototypes. Unfortunately, they typically are not adequately funded to bring these massive ideas to fruition.

The innovations in the middle are much lower-risk and far more likely to deliver results. The ideas in play typically are not new and not high-tech. In fact, they are grounded in common-sense principles that have been talked about for decades, such as sensible standardization of care processes, better coordination of care, more proactive care for high-risk populations, and more careful medical decision making. This is part of the reason that these initiatives are easily overlooked: they appear, at first glance, plain and boring, not truly innovative despite the powerful results that they deliver.

The most worthwhile investments in the middle of the spectrum are marked by a crucial choice: the commissioningof small but full-time clinical teams whose job it is to redesign and deliver better care for a particular patient population. Part-time teams are far less effective. A team only gains the flexibility needed to redesign care from scratch — literally, to rethink what each team member does at work each day — if the team is fully released from their existing job responsibilities.

This step seems to be a difficult one for many health systems to take. The typical pushback is that a full-time team, even a small one, is just too expensive. But that thinking may just be the residue of an entrenched fee-for-service mindset, where one simply does not deliver services that are not directly reimbursed. Under any kind of at-risk contract, however, these projects have high likelihoods of delivering both better outcomes for patients and a financial return on investment.